Current Concepts in Masculinizing Gender Surgery

Abstract

Learning Objectives: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital masculinization. 3. Recognize key steps and anatomy during chest-wall contouring and phalloplasty reconstruction. 4. Discuss major risks and complications of chest-wall contouring and phalloplasty reconstruction. Summary: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various masculinizing gender-affirming surgical procedures.

Strategies for innervation of the neophallus

“…It then travels distally with the cephalic vein towards the 1st and 2nd extensor compartments of the wrist [18,19] . The RFF's reliable neurovascular anatomy, including its innervation density, and its thin subcutaneous fat layer (helpful for flap shaping and a double tube procedure) make it a frequent "first-choice" option for phalloplasty [ Figure 2] [7,10,[20][21][22][23][24][25][26] . However, color mismatch, atrophy over time, and a conspicuous donor site may lead some individuals to select other flap options [7,10,20,21,24,27,28] .…”

“…Pedicled flap options Radial forearm flap [7,8,10,11,[20][21][22][23][24][25][26][27][28]68] Anterolateral thigh flap [7,20,21,23,34,35,68] Anterolateral thigh flap [7,21] Abdominal flaps [7,21] Osteocutaneous fibula flap [7,27,42,70] Groin flap [7] Musculocutaneous latissimus dorsi flap [40,41] Gracilis flap [7] Lateral arm flap [10,66] Superficial circumflex iliac artery perforator flap [45][46][47] patients reported tactile sensation, and 71.4% of patients reported the return of erogenous sensation. Monstrey et al [24] found that all patients regained tactile sensitivity 1 year following RFF phalloplasty.…”

“…The ALT flap offers a good color match, a less conspicuous donor site as compared to the RFF, and may be performed as a pedicled procedure [7,11,20,21,34,35] . The ALT flap may offer an advantage over the RFF by providing additional bulk, however, in many individuals, the amount of subcutaneous fat precludes its use in a double tube procedure [20,21] . Additionally, flap defatting should be undertaken with caution due to the risk of injury to the LFCN and subsequent loss of sensation in the flap [20] .…”

“…The ALT flap may offer an advantage over the RFF by providing additional bulk, however, in many individuals, the amount of subcutaneous fat precludes its use in a double tube procedure [20,21] . Additionally, flap defatting should be undertaken with caution due to the risk of injury to the LFCN and subsequent loss of sensation in the flap [20] . When comparing a onestage ALT flap to a one-stage RFF (both performed with urethral lengthening and vaginectomy), the ALT flap was found to have a higher rate of postoperative complications [36] .…”

Phalloplasty: understanding the chaos

“…However, restoration of cutaneous sensation in the phallus is always via straightforward nerve coaptation between a cutaneous nerve of the flap and a sensory nerve in the recipient site. This aspect of phalloplasty has been well covered in detail in two recent reviews and we will not elaborate further here [22][23][24] .…”